Stanford Swimming School - Brisbane - Groupon Registration Page

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Participant 1

*Responsible Person First Name :
*Responsible Person Last Name :
*Mobile:
*Email Address:
*Emergency Contact Person First Name: (Other than responsible person)
*Emergency Contact Person Last Name: (Other than responsible person)
*Emergency Contact Person Number: (Other than responsible person)
*Swimmer's First Name :
*Swimmer's Last Name:
Swimmer's Gender :
*Swimmer's date of birth :
*Swimmer's Street Address:
*Swimmer's Suburb:
*Swimmer's Health Condition :
*Swimmer's Swimming Ability :

	Agree * Information provided must be true and correct for insurance purposes